Formulations and uses of 2-hydroxy-5-phenylazobenzoic acid derivatives for the treatment of males

ABSTRACT

The instant application provides methods and compositions for the treatment of male subjects having ulcerative colitis.

RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.13/094,261, filed Apr. 26, 2011, Allowed, which claims the benefit ofU.S. Provisional Application No. 61/328,151, filed on Apr. 26, 2010. Theentire contents of each of the aforementioned application is herebyexpressly incorporated herein by reference.

BACKGROUND OF THE INVENTION

Balsalazide disodium is indicated for the treatment of gastrointestinaldiseases, for example mild to moderately active ulcerative colitis,radiation protosigmoidits, diverticulitis, irritable bowel syndrome(IBS) and colon cancer (see WO 95/18622). Balsalazide is acolon-specific, non-steroidal, anti-inflammatory aminosalicylatederivative. Balsalazide is also a prodrug containing 5-ASA, linked to4-amino benzoyl-β-alanine (“4-ABA”) by a diazo bond.

SUMMARY OF THE INVENTION

This invention relates to the use of balsalazide to treat, prevent, orameliorate gastrointestinal disorders in male subjects, e.g., mildly tomoderately active ulcerative colitis (see, for example, Schroeder et al.(1987) N Engl J. Med. 24; 317(26):1625-9).

More specifically, this invention relates to the use of balsalazide totreat male subjects having ulcerative colitis, irritable bowel syndromeand other non-inflammatory gastrointestinal (GI) conditions respondingto mesalamine and balsalazide (see, for example, U.S. Pat. Nos. 326,364;6,551,632; 6,475,518; 6,426,338; 6,277,836; 5,519,014; 5,476,669;5,196,205 and 6,645,530, which are hereby incorporated by reference).The invention also relates to the use of balsalazide to treatgastrointestinal disease in male subjects, alone or in combination withother therapies.

The invention is due, in part, to the unexpected finding thatadministration of balsalazide is more effective for treating malesubjects as compared to female subjects.

In one embodiment, the bioavailability of balsalazide is increasedcompared to administering balsalazide without food.

In one aspect, provided herein are methods for treating agastrointestinal disorder comprising administering to a male subject inneed of treatment a therapeutically effective amount of balsalazide. Inone embodiment, the therapeutically effective amount comprises about 6.5to about 6.8 g per day. In one embodiment, the therapeutically effectiveamount comprises about 6.6 g per day. In one embodiment, thetherapeutically effective amount comprises about 6.75 g per day. In oneembodiment, the therapeutically effective amount is a dosage regimen ofthree tablets of the formulation two times each day, wherein each tabletcomprises about 1100 mg of balsalazide. In one embodiment, thebalsalazide tablet is a film-coated tablet. In one embodiment, thetherapeutically effective amount is a dosage regimen of three capsulesof the formulation three times each day, wherein each capsule comprisesabout 750 mg of balsalazide. In one embodiment, the administration tothe subject occurs between about 30 minutes prior to about 1 hour afterconsuming food. In one embodiment, the gastrointestinal disordercomprises ulcerative colitis. In one embodiment, the ulcerative colitisis mild to moderately active ulcerative colitis.

In one aspect, provided herein are methods of decreasing a MMDAI scorein a male subject having ulcerative colitis comprising administering tothe subject a therapeutically effective amount of balsalazide, therebydecreasing the MMDAI score. In one embodiment, the therapeuticallyeffective amount comprises between about 6.5 to about 6.8 g per day. Inone embodiment, the therapeutically effective amount comprises about 6.6g per day. In one embodiment, the therapeutically effective amountcomprises about 6.75 g per day. In one embodiment, the therapeuticallyeffective amount is a dosage regimen of three tablets of the formulationtwo times each day, wherein each tablet comprises about 1100 mg ofbalsalazide. In one embodiment, the balsalazide tablet is a film-coatedtablet. In one embodiment, the therapeutically effective amount is adosage regimen of three capsules of the formulation three times eachday, wherein each capsule comprises about 750 mg of balsalazide. In oneembodiment, the MMDAI score is decreased by 3 or more points. In oneembodiment, the rectal bleeding component of the MMDAI score isdecreased by 1 or more points.

In one aspect, provided herein are methods of inducing clinicalremission of ulcerative colitis in a male subject comprising;administering to the subject a therapeutically effective amount ofbalsalazide, thereby inducing remission in the subject. In oneembodiment, the therapeutically effective amount comprises between about6.5 to about 6.8 g per day. In one embodiment, the therapeuticallyeffective amount comprises about 6.6 g per day. In one embodiment, thetherapeutically effective amount comprises about 6.75 g per day. In oneembodiment, the therapeutically effective amount is a dosage regimen ofthree tablets of the formulation two times each day, wherein each tabletcomprises about 1100 mg of balsalazide. In one embodiment, thebalsalazide tablet is a film-coated tablet. In one embodiment, thetherapeutically effective amount is a dosage regimen of three capsulesof the formulation three times each day, wherein each capsule comprisesabout 750 mg of balsalazide. In one embodiment, remission is defined byMMDAI component scores of zero for rectal bleeding and a combined scoreof 2 or less for bowel frequency and physician's assessment.

In one aspect, provided herein are methods of inducing mucosal healingin a male subject having ulcerative colitis comprising administering tothe subject a therapeutically effective amount of balsalazide, therebyinducing mucosal healing in the subject. In one embodiment, thetherapeutically effective amount comprises between about 6.5 to about6.8 g per day. In one embodiment, the therapeutically effective amountcomprises about 6.6 g per day. In one embodiment, the therapeuticallyeffective amount comprises about 6.75 g per day. In one embodiment, thetherapeutically effective amount is a dosage regimen of three tablets ofthe formulation two times each day, wherein each tablet comprises about1100 mg of balsalazide. In one embodiment, the balsalazide tablet is afilm-coated tablet. In one embodiment, the therapeutically effectiveamount is a dosage regimen of three capsules of the formulation threetimes each day, wherein each capsule comprises about 750 mg ofbalsalazide. In one embodiment, the mucosal healing is defined as animprovement in endoscopy/sigmoidoscopy score to 0 or 1.

Other embodiments of the invention are disclosed infra.

DETAILED DESCRIPTION OF THE FIGURES

FIG. 1 shows plasma levels of balsalazide and metabolites in fed andfasted states.

FIG. 2 shows the ratios of NASA/5-ASA of the capsules and tablets ofbalsalazide in the fed and fasted states.

FIG. 3 presents the balsalazide, 5-ASA and NASA plasma levels as a ratioof the female levels divided by the male levels. A value of 1.0 in thegraph would be indicative of equal absorption in both sexes.

DETAILED DESCRIPTION

Disclosed herein are compositions and methods of treatinggastrointestinal disorders in male subjects by administeringbalsalazide. In one embodiment, the balsalazide can be administered inthe form of a film-coated tablet containing 1.1 g balsalazide or forexample as 750 mg capsules. For example, an adult male dose is three 750mg capsules of balsalazide administered 3 times a day (6.75 g/day) withor without food for 8 weeks.

Before further description and in order that the invention may be morereadily understood, certain terms are first defined and collected herefor convenience.

Common pharmacologic term used herein refer are as follows: T_(max)(time to maximum concentration); C_(max) (observed maximumconcentration); kel (slope of terminal linear portion ofconcentration/time curve); T_(1/2) (half-life of balsalazide calculatedas: 0.693/Kel); AUC_((last)) (area under the curve to last quantifiableconcentration as measured by the trapezoidal rule); and AUC_((inf)) (theAUC value extrapolated to infinity calculated as:AUC_((inf))=AUC_((last))+C_((t)last)/Kel where C_((t))last is the lastmeasurable concentration).

The term “administration” or “administering” includes routes ofintroducing balsalazide to a subject to perform their intended function.The pharmaceutical preparations may be given by forms suitable for eachadministration route. Oral administration is preferred. Depending on theroute of administration, balsalazide can be coated with or disposed in aselected material to protect it from natural conditions that maydetrimentally affect its ability to perform its intended function.Balsalazide can be administered alone, or in conjunction with eitheranother agent or agents as described herein or with apharmaceutically-acceptable carrier, or both. Balsalazide can beadministered prior to the administration of the other agent,simultaneously with the agent, or after the administration of the agent.

“Chemotherapy,” as used herein, includes therapies administeredsystemically for the treatment of neoplastic disease processes (commonlycancer), and may include, for example, biological therapies such assmall molecule inhibitors, monoclonal antibodies (e.g., Iressa, Tarceva,Erbitux), or other biological agents administered with a similarobjective which may result in symptoms such as those herein described,e.g., inflammation of the intestine, those causing a disproportionateincidence of diarrhea or an increased risk of diarrhea.

The term “effective amount” includes an amount effective, at dosages andfor periods of time necessary, to achieve the desired result, e.g.,sufficient to treat or prevent an inflammatory bowel disease. Aneffective amount of balsalazide may vary according to factors such asthe disease state, age, and weight of the subject, and the ability ofbalsalazide to elicit a desired response in the subject. Dosage regimensmay be adjusted to provide the optimum therapeutic response. Aneffective amount is also one in which any side effects of balsalazideare outweighed by the therapeutically beneficial effects.

“Ameliorate,” “amelioration,” “improvement” or the like refers to, forexample, a detectable improvement or a detectable change consistent withimprovement that occurs in a subject or in at least a minority ofsubjects, e.g., in at least about 2%, 5%, 10%, 15%, 20%, 25%, 30%, 40%,50%, 60%, 70%, 75%, 80%, 85%, 90%, 95%, 98%, 100% or in a range betweenabout any two of these values. Such improvement or change may beobserved in treated subjects as compared to subjects not treated withbalsalazide, where the untreated subjects have, or are subject todeveloping, the same or similar disease, condition, symptom or the like.Amelioration of a disease, condition, symptom or assay parameter may bedetermined subjectively or objectively, e.g., self assessment by asubject(s), by a clinician's assessment or by conducting an appropriateassay or measurement, including, e.g., a quality of life assessment, aslowed progression of a disease(s) or condition(s), a reduced severityof a disease(s) or condition(s), or a suitable assay(s) for the level oractivity(ies) of a biomolecule(s), cell(s) or by detection of enteritisor diarrhea within a subject. Amelioration may be transient, prolongedor permanent or it may be variable at relevant times during or afterbalsalazide is administered to a subject or is used in an assay or othermethod described herein or a cited reference, e.g., within timeframesdescribed infra, or about 1 hour after the administration or use ofbalsalazide to about 3, 6, 9 months or more after a subject(s) hasreceived balsalazide.

As used herein, “administered with food” refers to, for example, anyfood product, solid or liquid, with caloric content. Preferably the foodis a solid food with sufficient bulk and fat content that it is notrapidly dissolved and absorbed in the stomach. More preferably the foodis a meal, such as breakfast, lunch or dinner. The dosage of balsalazidemay be administered to the subject, for example, between about 30minutes prior to about 2 hours after eating a meal, most advantageouslythe dosage is administered within 15 minutes of eating a meal. The terms“without food”, “fasted” and “an empty stomach” refer to, for example,the condition of not having consumed solid food for about 1 hour priorto until about 2 hours after such consumption.

The “modulation” of, e.g., a symptom, level or biological activity of amolecule, or the like, refers, for example, that the symptom oractivity, or the like is detectably increased or decreased. Suchincrease or decrease may be observed in treated subjects as compared tosubjects not treated with balsalazide, where the untreated subjectshave, or are subject to developing, the same or similar disease,condition, symptom or the like. Such increases or decreases may be atleast about 2%, 5%, 10%, 15%, 20%, 25%, 30%, 40%, 50%, 60%, 70%, 75%,80%, 85%, 90%, 95%, 98%, 100%, 150%, 200%, 250%, 300%, 400%, 500%, 1000%or more or within any range between any two of these values. Modulationmay be determined subjectively or objectively, e.g., by the subject'sself assessment, by a clinician's assessment or by conducting anappropriate assay or measurement, including, e.g., quality of lifeassessments or suitable assays for the level or activity of molecules,cells or cell migration within a subject. Modulation may be transient,prolonged or permanent or it may be variable at relevant times during orafter balsalazide is administered to a subject or is used in an assay orother method described herein or a cited reference, e.g., within timesdescried infra, or about 1 hour of the administration or use ofbalsalazide to about 3, 6, 9 months or more after a subject(s) hasreceived balsalazide. The term “modulate” may also refer to increases ordecreases in the activity of a cell in response to exposure to abalsalazide, e.g., the inhibition of proliferation and/or induction ofdifferentiation of at least a sub-population of cells in an animal suchthat a desired end result is achieved, e.g., a therapeutic result ofbalsalazide used for treatment may increase or decrease over the courseof a particular treatment.

The term “obtaining” as in “obtaining balsalazide” is intended toinclude purchasing, synthesizing or otherwise acquiring balsalazide.

As used herein, the term “prophylactically effective amount” refers tothe amount of a therapy (e.g., a composition comprising balsalazide)which is sufficient to result in the prevention of the development,recurrence, or onset of enteritis and/or diarrhea or one or moresymptoms thereof, or to enhance or improve the prophylactic effect(s) ofanother therapy. In one embodiment, the language “a prophylacticallyeffective amount” of a compound refers to an amount of balsalazide whichis effective, upon single or multiple dose administration to thesubject, in preventing or treating, for example, colitis, Crohn'sdisease, diverticulits, irritable bowel syndrome (IBS), enteritis and/ordiarrhea.

The phrases “systemic administration,” “administered systemically,”“peripheral administration,” and “administered peripherally,” as usedherein mean the administration of balsalazide, drug or other material,such that it enters the subject's system and, thus, is subject tometabolism and other like processes, for example, subcutaneousadministration.

The language “therapeutically effective amount” of balsalazide refers toan amount of balsalazide which is effective, upon single or multipledose administration to the subject, in inhibiting the bacterial growthand/or invasion, or in decreasing symptoms of bacterial infection in asubject with such a bacterial infection sooner that expected in theabsence of such treatment. “Therapeutically effective amount” alsorefers to the amount of a therapy (e.g., a composition comprisingbalsalazide), which is sufficient to reduce the severity of enteritisand/or diarrhea, reduce the duration of enteritis and/or diarrhea,prevent the advancement of enteritis and/or diarrhea, cause regressionof enteritis and/or diarrhea, ameliorate one or more symptoms associatedwith enteritis and/or diarrhea, or enhance, facilitate, or improve thetherapeutic effect(s) of another therapy.

As used herein, the terms “prevent,” “preventing,” and “prevention”refer to the prevention of the recurrence, onset, or development ofcolitis (including, ulcerative, active, moderate, mild or severecolitis), enteritis and/or diarrhea or one or more symptoms thereof in asubject resulting from the administration of an abdominopelvic therapyor from travel. Preventing includes protecting against radiation inducedenteritis, protecting against radiation induced injury to the mucosa ofthe colon, protecting against radiation induced colorectal inflammation,and/or radiation-induced inflammation or bacterial invasion of otherportions of the alimentary tract. For example, balsalazide may beformulated as a mouthwash to treat or ameliorate radiation-inducedesophagitis or other radiation-induced mucositis. For example,balsalazide may be given to a traveler prior to travel to reduce orprevent enteritis or diarrhea.

As used herein, the terms “subject” and “subjects” includes maleorganisms which are capable of suffering from a gastrointestinaldisease, e.g., colitis, e.g., ulcerative colitis, e.g., mild, moderateor severe, or who could otherwise benefit from the administration of abalsalazide and refer to an animal, preferably a mammal, including anon-primate (e.g., a cow, pig, horse, cat, or dog), a primate (e.g., amonkey, chimpanzee, or human), and more preferably a human male.

Susceptible to gastrointestinal diseases, e.g., enteritis, diarrhea,colon cancer, ulcerative colitis, is meant to include subjects at riskof developing the gastrointestinal diseases, and the like, and subjectswho have suffered from colitis in the past, subjects having a familyhistory of colitis or cancer and the like.

As used herein, the terms “treat,” “treatment,” and “treating” refer tothe reduction of the progression, severity, and/or duration of colitis,enteritis and/or diarrhea or amelioration of one or more symptomsthereof, wherein such reduction and/or amelioration result from theadministration of one or more therapies (e.g., a composition comprisingbalsalazide).

In some embodiments, “clinical improvement” is defined as having both a≧3 point improvement from baseline in the MMDAI score and a ≧1 pointimprovement from baseline in the rectal bleeding subscore. In someembodiments, “clinical remission” is defined as a score of 0 for rectalbleeding and a combined score of ≦2 for bowel frequency and physician'sassessment using the MMDAI subscale. In some embodiments, “mucosalhealing” is defined as an endoscopy/sigmoidoscopy score of 0 or 1, wherea score of 1 includes signs of erythema or decreased vascular pattern;by definition, the presence of friability indicates a score of 2 or 3.

The phrase “pharmaceutically acceptable” refers to compositionscontaining such compounds, and/or dosage forms which are, within thescope of sound medical judgment, suitable for use in contact with thetissues of human beings and animals without excessive toxicity,irritation, allergic response, or other problem or complication,commensurate with a reasonable benefit/risk ratio.

Determining a subject in need thereof may be by one or more ofcolonoscopy, symptom analysis, or medical assessment and other methodsdescribed infra.

Balsalazide and Pharmaceutical Compositions

Balsalazide is a prodrug of mesalamine (5-aminosalicylic acid, 5-ASA).The mechanism of action of 5-ASA is unknown, but appears to be local tothe colonic mucosa rather than systemic. Mucosal production ofarachidonic acid metabolites, both through the cyclooxygenase pathways,i.e., prostanoids, and through the lipoxygenase pathways, i.e.,leukotrienes and hydroxyeicosatetraenoic acids, is increased in patientswith ulcerative colitis, and it is possible that 5-ASA diminishesinflammation by blocking production of arachidonic acid metabolites inthe colon.

Balsalazide disodium is a a prodrug that is enzymatically cleaved toproduce mesalamine (5-aminosalicylic acid, 5-ASA), an anti-inflammatorydrug. It is a stable, odorless, orange to yellow, microcrystallinepowder. It is freely soluble in water and isotonic saline, sparinglysoluble in methanol and ethanol, and practically insoluble in all otherorganic solvents. Balsalazide disodium has the chemical name(E)-5-[[4-[[(2-carboxyethyl) amino]carbonyl]phenyl]azo]-2-hydroxybenzoicacid, disodium salt, dihydrate (Molecular Weight: 437.32; MolecularFormula: C₁₇H₁₃N₃O₆Na₂.2H₂O).

Balsalazide is the generic name for GIAZO®. Examples of uses andmanufacture of balsalazide may be found, for example in U.S. Pat. Nos.6,197,341; 5,905,073; 5,498,608; and 6,326,364; which are herebyincorporated by reference in their entirety. Balsalazide is useful inthe methods described herein to increase their bioavailability andefficacy

Each GIAZO tablet contains 1.1 g of balsalazide disodium, film-coatedfor oral delivery. Balsalazide disodium is insoluble in acid, butsoluble at a pH of at least 4.5. Inactive ingredients comprisehypromellose, magnesium stearate, and Opadry II Yellow. The sodiumcontent of each tablet is approximately 126 mg.

Following oral administration, balsalazide is cleaved by azoreductasesproduced by anaerobic bacteria, found in the gut, to release equimolarquantities of 5-ASA, the active moiety, and 4-aminobenzoyl-β-alanine(4-ABA), a carrier moiety. Both of these moieties are N-acetylated toform N-Ac-5-ASA and N-Ac-4-ABA, respectively.

The released 4-ABA carrier component is poorly absorbed and largelyeliminated in the feces (Ragunath K and Williams J G. Aliment Pharmcol.Ther. 2001; 15:1549-1554). The local presence of 5-ASA is the basis forthe effectiveness of this class of drugs and mucosal 5-ASAconcentrations are correlated inversely with UC disease activity (FrieriG, Giacomelli R, Pimpo M. et al. Gut 2000; 47:410-414). While the actualmechanism of action of 5-ASA is not completely understood, systemicexposure of 5-ASA is thought to be responsible for the sides effectsassociated with treatment. Most prevalent in studies on balsalazide isheadache (Green J B Gastroenterology 1999; 117:1513-1514) and lowersystemic levels of 5-ASA may contribute to a lower incidence of headacheas observed in some trials (Levine D S, Riff D S, Pruitt R et al. Am. J.Gastroenterol. 2002; 9:1398-1407). Dose regimens that increase the localmucosal concentration of the active therapeutic moiety and decrease thesystemic absorption of 5-ASA are therefore preferred.

While 5-ASA is the active therapeutic moiety of balsalazide, it israpidly converted to the metabolite N-acetyl-5-ASA (5-Ac-5-ASA; NASA) inthe mucosa (Allgayer H, Ahnfelt N O, Kruis W et al Gastroenterology.1989; 97:38-41). Approximately, 12% of the oral dose can be measured inthe blood as this metabolite as compared to <2% of the oral dose of5-ASA that is systemically absorbed (van Hogezand R A, van Hees P A, vanGorp J P, van Lier H J, Bakker J H, Double-blind comparison of5-aminosalicylic acid and acetyl-5-aminosalicylic acid suppositories insubjects with idiopathic proctitis Aliment Pharmacol Ther. 1988February; 2(1):33-40).

It has surprisingly been found that the administration of balsalazide toa male subject experiencing ulcerative colitis, e.g., mildly tomoderately active ulcerative colitis, reduces symptoms of the condition.Balsalazide is the generic name for a 2-hydroxy-5-phenylazobenzoic acidderivative in which an aminosalicylate moiety, 5-aminosalicylic acid(5-ASA) (mesalamine), is linked to a carrier molecule,4-aminobenzoyl-β-alanine (4-ABA), through an azo-bond. Disodiumbalsalazide is highly water-soluble and is cleaved in the colon torelease mesalamine, which is the therapeutically active portion of themolecule, as well as 4-aminobenzol-β-alamine, which is the carriermoiety. Mesalamine is 5-aminosaliacylic acid and appears to acttopically.

One mechanism for the surprising observation of a increased efficacy inmales to balsalazide is the finding that that female subjects displaygreater absorption of balsalazide and its metabolites, 5-ASA andN-acetyl-5-ASA (NASA) in the blood, e.g., systemic bioavailability.Balsalazide and its metabolites work topically in the colon, e.g.,colonic bioavailability, to treat the underlying pathology, the greaterabsorption into the blood compartment would mean a lowering of theirlevel in the colon and less colonic bioavailability. This observation isshown in FIG. 3, where the balsalazide, 5-ASA and NASA plasma levels arepresented as a ratio of the female levels divided by the male levels.Thus, a value of 1.0 in the graph would be indicative of equalabsorption in both sexes. As is evident from FIG. 3, the female subjectsconsistently display greater plasma levels relative to the malesubjects. These range from 10-60% greater in the fasted state to 25-120%greater in the fed state.

The use of balsalazide to treat gastrointestinal disorders is especiallybeneficial because balsalazide is metabolized by intestinal microflorato the active form, 5-ASA, thus ensuring delivery of the active drug tothe bowel without loss via absorption more proximally in the intestinaltract. Balsalazide also exhibits fewer side effects than other 5-ASAprodrugs and it may be administered to subjects with sulpha allergies.Balsalazide is also beneficial because the active component has beendemonstrated to directly scavenge free radicals, which may reducesubsequent inflammatory response. Dosages, according to certainpreferred embodiments, range from between about 6.0 mg to about 14000 mgof balsalazide administered daily. For example, a dose is three 1.1 gbalsalazide tablets may be taken 2 times a day for a total of 6.6 g perday. Other appropriate dosages for methods according to this inventionmay be determined by health care professionals or by the subject. Theamount of balsalazide administered daily may be increased or decreasedbased on the weight, age, health, sex or medical condition of thesubject. One of skill in the art would be able to determine the properdose for a subject based on this disclosure.

Methods of Treatment

Described herein are methods of treating male subjects suffering from orsusceptible to gastrointestinal disorders by administering balsalazideto a subject.

According to one aspect, provided herein are methods for treating a malesubject having or susceptible to developing a gastrointestinal disorder,e.g., ulcerative colitis, comprising administering to the male subject atherapeutically effective amount of balsalazide.

Therapeutically effective amounts, according to the methods describedherein include doses of about 6.0 g/day to about 7 g/day, for example,as tablets or capsules. Therapeutically effective amounts and dosageregimens include, administering three tablets or capsules of theformulation once, twice or three two times each day, wherein each tabletor capsule comprises from about 750 mg to about 1100 mg of balsalazide.For example, a therapeutically effective amount of balsalazide may beadministration of three 750 mg capsules three times a day (6.75 g/day).A more preferred administration to males comprises administration ofthree 1.1 g tablets two times a day.

The administration to the subject can occur, for example, between about30 minutes prior to about 2 hours after consuming food. Theadministration with food may also be at the same time as the consumptionof the food. Also, the administration to the subject may be, forexample, immediately after the consumption of food up to about 1 hourafter the consumption. The food may comprise, for example, applesauce ora high-fat meal.

According to one aspect, provided herein are methods of decreasing themodified Mayo Disease Activity Index (MMDAI) score of a male subjecthaving ulcerative colitis by administering a therapeutically effectiveamount of balsalazide to the subject. In one embodiment, the MMDAI scoreis decreased by three or more points or the rectal bleeding component ofthe MMDAI score is decreased by one or more points. The modified MayoDisease Activity Index (MMDAI) is a sum of four subscores (bowelfrequency, rectal bleeding, endoscopic appearance, and physician'sglobal assessment), each ranging from 0 to 3, with higher scoresindicating worse disease. See for example, Schroeder et al. (1987) NEngl J. Med. 24; 317(26):1625-9.

According to one aspect, provided herein are methods of inducingclinical remission of ulcerative colitis in male subjects. In oneembodiment, remission is defined as an MMDAI component score of 0 forrectal bleeding and a combined score of two or less for the MMDAIcomponents of bowel frequency and physician's assessment.

According to one aspect, provided herein are methods of inducing mucosalhealing in male subjects having ulcerative colitis. In one embodiment,mucosal healing is determined by an improvement in theendoscopy/sigmoidoscopy score of 0 to 1.

In one embodiment, the balsalazide is from a container comprisinglabeling advising that balsalazide should be administered with food.

According to one aspect, a method of treating a subject suffering from agastrointestinal disease, e.g., mild to moderately active ulcerativecolitis, comprises administering to the subject a therapeuticallyeffective amount of balsalazide. In one embodiment, balsalazide issodium balsalazide dihydrate. In one embodiment, the pharmaceuticalcomposition is administered orally to an individual suffering from or atrisk to develop a gastrointestinal disorder in a daily dosage range ofabout 6 to about 7 grams per day, e.g., 6.6 g.

In another embodiment, the gastrointestinal disease is mild tomoderately active ulcerative colitis.

Yet another aspect of this invention relates to a method of treating amale subject with balsalazide who is in need thereof. Identifying asubject in need of such treatment can be in the judgment of a subject ora health care professional and can be subjective (e.g., opinion) orobjective (e.g., measurable by a test or diagnostic method).

Balsalazide may be administered prior to, during, and/or after thetreatment therapies or travel or exposure to other at risk conditions.Balsalazide may be administered, for example, once a day, twice a day,three times a day, or four times a day. Balsalazide may be administeredin doses, for example of about 6.6 g/day. Balsalazide may beadministered, for example, in tablet form, powered form, liquid for orin capsules. Balsalazide tablets may be film-covered tablets marketedunder the brand name GIAZO®.

In certain embodiments, balsalazide is administered to a male subjectfrom between about 2 weeks to about 6 weeks in duration, from betweenabout 8 weeks to about 12 weeks in duration, or from between 1 day toabout 7 days. Balsalazide may be administered intermittently orcontinuously during the course of treatment.

For any of the embodiments, balsalazide may be administered, forexample, once daily, twice daily, three times daily, or four times dailyto a subject. In some particularly preferred methods of the presentinvention comprise administering balsalazide twice daily to the subjectbecause it may, for example, minimize the side effects and increasesubject compliance.

Dosages, according to certain preferred embodiments, are about 6.6 g ofbalsalazide administered daily. Other appropriate dosages for methodsaccording to this invention may be determined by health careprofessionals or by the subject. The amount of balsalazide administereddaily may be increased or decreased based on the weight, age, health,sex or medical condition of the subject. One of skill in the art wouldbe able to determine the proper dose for a subject based on thisdisclosure.

In certain embodiments, one or more formulations and one or more othertherapies (e.g., prophylactic or therapeutic agents) are cyclicallyadministered. Cycling therapy involves the administration of a firsttherapy (e.g., a first prophylactic or therapeutic agent) for a periodof time, followed by the administration of a second therapy (e.g., asecond prophylactic or therapeutic agent) for a period of time,optionally, followed by the administration of a third therapy (e.g.,prophylactic or therapeutic agent) for a period of time and so forth,and repeating this sequential administration, e.g., the cycle in orderto reduce the development of resistance to one of the therapies, toavoid or reduce the side effects of one of the therapies, and/or toimprove the efficacy of the therapies.

In certain embodiments, the administration of the same formulations ofthe invention may be repeated and the administrations may be separatedby at least 1 day, 2 days, 3 days, 5 days, 10 days, 15 days, 30 days, 45days, 2 months, 75 days, 3 months, or at least 6 months.

In other embodiments, the administration of the same therapy (e.g.,prophylactic or therapeutic agent) other than a gastro-resistantbalsalazide formulation may be repeated and the administration may beseparated by at least at least 1 day, 2 days, 3 days, 5 days, 10 days,15 days, 30 days, 45 days, 2 months, 75 days, 3 months, or at least 6months.

Certain indications may require longer treatment times. Short-termtreatments include, for example, treatment for 1 to about 7 days.Long-term treatments with balsalazide, include for example, treatmentfor 15 days, 3 months, 9 months, 7 days/month for three months, 7days/month for three to twelve months or any time in-between or longer.One of skill in the art, having the benefit of this disclosure wouldunderstand how to vary the dosage for a particular subject or intendedresult. Dosage regimens will vary depending on the age, size, andcondition of the subject. For example, depending on the severity of thedisease, or injury whether it is a new disease state or a relapse orrecurrence, etc.

Toxicity and efficacy of the prophylactic and/or therapeutic protocolsof the present invention can be determined by standard pharmaceuticalprocedures in cell cultures or experimental animals, e.g., fordetermining the LD₅₀ (the dose lethal to 50% of the population) and theED₅₀ (the dose therapeutically effective in 50% of the population). Thedose ratio between toxic and therapeutic effects is the therapeuticindex and it can be expressed as the ratio LD₅₀/ED₅₀. Prophylacticand/or therapeutic agents that exhibit large therapeutic indices arepreferred. While prophylactic and/or therapeutic agents that exhibittoxic side effects may be used, care should be taken to design adelivery system that targets such agents to the site of affected tissuein order to minimize potential damage to uninfected cells and, thereby,reduce side effects.

The total daily dosage of balsalazide formulations, for example ofbalsalazide, can be about 6.6 g. For example, in general, the totaldaily adult dosage of balsalazide in formulations of the presentinvention ranges from about 6000 mg to about 7000 mg, about, about 6200to about 6800 mg, or any whole number or fractional amount in between.In one embodiment, a single dose contains about 1100 mg of balsalazide.

Balsalazide may be provided as a film-coated tablet formulation.

Balsalazide formulations may be of any polymorphic or amorphous form ofbalsalazide.

In an embodiment, balsalazide is administered to the subject using apharmaceutically-acceptable formulation, e.g., apharmaceutically-acceptable formulation that provides sustained deliveryof balsalazide to a subject for at least 12 hours, 24 hours, 36 hours,48 hours, one week, two weeks, three weeks, or four weeks after thepharmaceutically-acceptable formulation is administered to the subject.

In some embodiments, it may be desirable to administer thepharmaceutical compositions of the invention locally to the area in needof treatment. This may be achieved by, for example, local infusionduring surgery, or topical application, e.g., in conjunction with awound dressing after surgery, by injection, by means of a catheter, bymeans of a suppository, or by means of an implant (the implant being ofa porous, non-porous, or gelatinous material, including membranes, suchas sialastic membranes, or fibers). In one embodiment, administrationcan be by direct injection at the site, e.g., enema. In anotherembodiment, balsalazide can be formulated in a viscous or non-viscoussolution for oral administration. In a separate embodiment, balsalazidecan be formulated in a viscous or non-viscous mixture containing a painreliever, e.g., lidocaine.

In certain embodiments, these pharmaceutical compositions of balsalazideare suitable for topical or oral administration to a subject. In otherembodiments, as described in detail below, the pharmaceuticalcompositions of the present invention may be specially formulated foradministration in solid or liquid form, including those adapted for thefollowing: (1) oral administration, for example, drenches (aqueous ornon-aqueous solutions or suspensions), tablets, boluses, powders,granules, pastes; topical application, for example, as a cream, ointmentor spray applied to the gastrointestinal tract; intrarectally, forexample, as a pessary, cream or foam; or aerosol, for example, as anaqueous aerosol, liposomal preparation or solid particles containing thecompound.

The phrase “pharmaceutically acceptable” refers to compositionscontaining such compounds, and/or dosage forms which are, within thescope of sound medical judgment, suitable for use in contact with thetissues of human beings and animals without excessive toxicity,irritation, allergic response, or other problem or complication,commensurate with a reasonable benefit/risk ratio.

It is advantageous to administer balsalazide to males because less ofthe molecule and metabolites are absorbed systemically leaving more inthe colon for local colonic bioavailability. For example, see FIG. 3,which shows that with or without food, less of the balsalazide andmetabolites are systemically absorbed in the men taking the compound.This was previously an unappreciated aspect of administering balsalazideand it was surprising to find that administration to males has increasedefficacy as compared to females.

Article of Manufacture

The article of manufacture comprises, for example, a container holding afilm-coated pharmaceutical composition or a capsule or a combination ofthe two suitable for oral administration of balsalazide in combinationwith printed labeling instructions providing a discussion of when aparticular dosage form should be administered to male subjects.Exemplary dosage forms and administration protocols are described infra.The composition will be contained in any suitable container capable ofholding and dispensing the dosage form and which will not significantlyinteract with the composition and will further be in physical relationwith the appropriate labeling. The labeling instructions will beconsistent with the methods of treatment as described hereinbefore. Thelabeling may be associated with the container by any means that maintaina physical proximity of the two, by way of non-limiting example, theymay both be contained in a packaging material such as a box or plasticshrink wrap or may be associated with the instructions being bonded tothe container such as with glue that does not obscure the labelinginstructions or other bonding or holding means.

Another aspect of this invention is an article of manufacture thatcomprises a container containing a pharmaceutical composition comprisingbalsalazide wherein the container holds preferably balsalazidecomposition in unit dosage form and is associated with printed labelinginstructions advising of efficacy of the pharmaceutical composition whenadministered to male subjects.

The phrase “pharmaceutically-acceptable carrier” includespharmaceutically-acceptable material, composition or vehicle, such as aliquid or solid filler, diluent, excipient, solvent or encapsulatingmaterial, involved in carrying or transporting the subject chemical fromone organ, or portion of the body, to another organ, or portion of thebody. Each carrier is “acceptable” in the sense of being compatible withthe other ingredients of the formulation and not injurious to thesubject. Some examples of materials which can serve aspharmaceutically-acceptable carriers include: (1) sugars, such aslactose, glucose and sucrose; (2) starches, such as corn starch andpotato starch; (3) cellulose, and its derivatives, such as sodiumcarboxymethyl cellulose, ethyl cellulose and cellulose acetate; (4)powdered tragacanth; (5) malt; (6) gelatin; (7) talc; (8) excipients,such as cocoa butter and suppository waxes; (9) oils, such as peanutoil, cottonseed oil, safflower oil, sesame oil, olive oil, corn oil andsoybean oil; (10) glycols, such as propylene glycol; (11) polyols, suchas glycerin, sorbitol, mannitol and polyethylene glycol; (12) esters,such as ethyl oleate and ethyl laurate; (13) agar; (14) bufferingagents, such as magnesium hydroxide and aluminum hydroxide; (15) alginicacid; (16) pyrogen-free water; (17) isotonic saline; (18) Ringer'ssolution; (19) ethyl alcohol; (20) phosphate buffer solutions; and (21)other non-toxic compatible substances employed in pharmaceuticalformulations.

Wetting agents, emulsifiers and lubricants, such as sodium laurylsulfate and magnesium stearate, as well as coloring agents, releaseagents, coating agents, sweetening, flavoring and perfuming agents,preservatives and antioxidants can also be present in the compositions.

Examples of pharmaceutically-acceptable antioxidants include: (1) watersoluble antioxidants, such as ascorbic acid, cysteine hydrochloride,sodium bisulfate, sodium metabisulfite, sodium sulfite and the like; (2)oil-soluble antioxidants, such as ascorbyl palmitate, butylatedhydroxyanisole (BHA), butylated hydroxytoluene (BHT), lecithin, propylgallate, alpha-tocopherol, and the like; and (3) metal chelating agents,such as citric acid, ethylenediamine tetraacetic acid (EDTA), sorbitol,tartaric acid, phosphoric acid, and the like.

Compositions containing balsalazide include, for example, those suitablefor oral, nasal, topical (including buccal and sublingual), rectal,vaginal, aerosol percutaneous, and/or parenteral administration. Forinstance, to treat an infected external biliary drain, balsalazide couldbe administered percutaneously via that drain, thus resulting in an“intrabiliary” administration. The compositions may conveniently bepresented in unit dosage form and may be prepared by any methods wellknown in the art of pharmacy. The amount of active ingredient which canbe combined with a carrier material to produce a single dosage form willvary depending upon the host being treated, the particular mode ofadministration. The amount of active ingredient which can be combinedwith a carrier material to produce a single dosage form will generallybe that amount of the compound which produces a therapeutic effect.Generally, out of 100%, this amount will range from about 1% to about99% of active ingredient, preferably from about 5% to about 70%, morepreferably from about 10% to about 30% active ingredient.

Methods of preparing these balsalazide compositions include the step ofbringing into association balsalazide with the carrier and, optionally,one or more accessory ingredients. In general, the formulations areprepared by uniformly and intimately bringing into association withbalsalazide with liquid carriers, or finely divided solid carriers, orboth, and then, if necessary, shaping and coating the product.

Balsalazide compositions suitable for oral administration may be in theform of capsules, cachets, pills, tablets, lozenges (using a flavoredbasis, usually sucrose and acacia or tragacanth), powders, granules, oras a solution or a suspension in an aqueous or non-aqueous liquid, or asan oil-in-water or water-in-oil liquid emulsion, or as an elixir orsyrup, or as pastilles (using an inert base, such as gelatin andglycerin, or sucrose and acacia) and/or as mouth washes and the like,each containing a predetermined amount of balsalazide as an activeingredient. A compound may also be administered as a bolus, electuary orpaste.

A tablet may be made by compression or molding, optionally with one ormore accessory ingredients. Compressed tablets may be prepared usingbinder (for example, gelatin or hydroxypropylmethyl cellulose),lubricant, inert diluent, preservative, disintegrant (for example,sodium starch glycolate or cross-linked sodium carboxymethyl cellulose),surface-active or dispersing agent. Molded tablets may be made bymolding in a suitable machine a mixture of the powdered activeingredient moistened with an inert liquid diluent.

The tablets, and other solid dosage forms of the pharmaceuticalcompositions of the present invention, such as dragees, capsules, pillsand granules, may optionally be scored or prepared with coatings andshells, such as film coatings and other coatings well known in thepharmaceutical-formulating art. They may also be formulated so as toprovide slow or controlled release of the active ingredient thereinusing, for example, hydroxypropylmethyl cellulose in varying proportionsto provide the desired release profile, other polymer matrices,liposomes and/or microspheres. They may be sterilized by, for example,filtration through a bacteria-retaining filter, or by incorporatingsterilizing agents in the form of sterile solid compositions which canbe dissolved in sterile water, or some other sterile injectable mediumimmediately before use. These compositions may also optionally containopacifying agents and may be of a composition that they release theactive ingredient(s) only, or preferentially, in a certain portion ofthe gastrointestinal tract, optionally, in a delayed manner. Examples ofembedding compositions which can be used include polymeric substancesand waxes. The active ingredient can also be in micro-encapsulated form,if appropriate, with one or more of the above-described excipients.

Liquid dosage forms for oral administration of balsalazide includepharmaceutically-acceptable emulsions, microemulsions, solutions,suspensions, syrups and elixirs. In addition to the active ingredient,the liquid dosage forms may contain inert diluents commonly used in theart, such as, for example, water or other solvents, solubilizing agentsand emulsifiers, such as ethyl alcohol, isopropyl alcohol, ethylcarbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propyleneglycol, 1,3-butylene glycol, oils (in particular, cottonseed, groundnut,corn, germ, olive, castor and sesame oils), glycerol, tetrahydrofurylalcohol, polyethylene glycols and fatty acid esters of sorbitan, andmixtures thereof.

Pharmaceutical compositions of the invention for rectal administrationmay be presented as a suppository, which may be prepared by mixingbalsalazide with one or more suitable nonirritating excipients orcarriers comprising, for example, cocoa butter, polyethylene glycol, asuppository wax or a salicylate, and which is solid at room temperature,but liquid at body temperature and, therefore, will melt in the rectumand release the active agent.

Dosage forms for the topical or transdermal administration ofbalsalazide include powders, sprays, ointments, pastes, creams, lotions,gels, solutions, patches and inhalants. Balsalazide may be mixed understerile conditions with a pharmaceutically-acceptable carrier, and withany preservatives, buffers, or propellants which may be required.

Examples of suitable aqueous and nonaqueous carriers, which may beemployed in the pharmaceutical compositions of the invention includewater, ethanol, polyols (such as glycerol, propylene glycol,polyethylene glycol, and the like), and suitable mixtures thereof,vegetable oils, such as olive oil, and injectable organic esters, suchas ethyl oleate. Proper fluidity can be maintained, for example, by theuse of coating materials, such as lecithin, by the maintenance of therequired particle size in the case of dispersions, and by the use ofsurfactants.

These compositions may also contain adjuvants such as preservatives,wetting agents, emulsifying agents and dispersing agents. Prevention ofthe action of microorganisms may be ensured by the inclusion of variousantibacterial and antifungal agents, for example, paraben,chlorobutanol, phenol sorbic acid, and the like. It may also bedesirable to include isotonic agents, such as sugars, sodium chloride,and the like into the compositions. In addition, prolonged absorption ofthe injectable pharmaceutical form may be brought about by the inclusionof agents that delay absorption such as aluminum monostearate andgelatin.

In some cases, in order to prolong the effect of a drug, it is desirableto slow the absorption of the drug from subcutaneous or intramuscularinjection. This may be accomplished by the use of a liquid suspension ofcrystalline or amorphous material having poor water solubility. The rateof absorption of the drug then depends upon its rate of dissolution thatin turn may depend upon crystal size and crystalline form.Alternatively, delayed absorption of a parenterally-administered drugform is accomplished by dissolving or suspending the drug in an oilvehicle.

Injectable depot forms are made by forming microencapsule matrices ofbalsalazide in biodegradable polymers such as polylactide-polyglycolide.Depending on the ratio of drug to polymer, and the nature of theparticular polymer employed, the rate of drug release can be controlled.Examples of other biodegradable polymers include poly(orthoesters) andpoly(anhydrides). Depot injectable formulations are also prepared byentrapping the drug in liposomes or microemulsions which are compatiblewith body tissue.

When balsalazide are administered as pharmaceuticals, to humans andanimals, they can be given per se or as a pharmaceutical compositioncontaining, for example, 0.1 to 99.5% (more preferably, 0.5 to 90%) ofactive ingredient in combination with a pharmaceutically-acceptablecarrier.

In some cases, to ameliorate, for example, simultaneously, conditionsassociated with the condition for which balsalazide is administered,such as pain, candida, dysphagia, odynophagia, mucositis, esophagitis,pneumonitis, stomatitis, or xerostomia, balsalazide may be formulated asa combination with other appropriate agents including but not limited tonystatin, ketoconazole, fluconazole, lidocaine, benzocaine,diphenhydramine, dimenhydrinate, azelastine, cetirizine, hydrocortisone,prednisone, prednisolone, dexamethasone, triamcinolone, beclomethosone,budesonide, mometasone, or other steroid, local anesthetic, anti-fungal,or antihistamine agents. This formulation may take the form of a viscousor non-viscous liquid, a topically applied compound, an aerosol, or aninjectable.

Regardless of the route of administration selected, balsalazide, whichmay be used in a suitable hydrated form, and/or the pharmaceuticalcompositions of the present invention, are formulated intopharmaceutically-acceptable dosage forms by conventional methods knownto those of skill in the art.

Actual dosage levels and time course of administration of the activeingredients in the pharmaceutical compositions of the invention may bevaried so as to obtain an amount of the active ingredient which iseffective to achieve the desired therapeutic response for a particularsubject, composition, and mode of administration, without being toxic tothe subject. Exemplary dosage forms are disclosed infra.

Packaged compositions are also provided, and may comprise atherapeutically effective amount of balsalazide. Balsalazide and apharmaceutically acceptable carrier or diluent, wherein the compositionis formulated for treating a subject suffering from or susceptible to abowel disorder, and packaged with instructions to treat a subjectsuffering from or susceptible to a bowel disorder.

Prescribing Information

A subject being administered balsalazide may be informed of one or moreof the following:

GIAZO, film-coated tablets containing 1.1 g balsalazide, is indicatedfor the treatment of mildly to moderately active ulcerative colitis inmale patients 18 years of age and older; effectiveness in femalepatients was not demonstrated in clinical studies. Safety andeffectiveness of GIAZO therapy beyond 8 weeks have not been established.

For treatment of active ulcerative colitis in adult male patients, theusual dose is three 1.1 g GIAZO tablets to be taken 2 times a day withfood (6.6 g per day) for up to 8 weeks.

GIAZO is available as yellow, oval, film-coated tablets containing 1.1 gbalsalazide disodium, with BZT debossed on one side of the tablet.

GIAZO is contraindicated in patients with hypersensitivity tosalicylates, balsalazide, or their metabolites, or to any of thecomponents of GIAZO tablets. Hypersensitivity reactions may include, butare not limited to the following: anaphylaxis, bronchospasm, and skinreaction.

Mesalamine has been associated with an acute intolerance syndrome thatmay be difficult to distinguish from an exacerbation of ulcerativecolitis. In controlled clinical studies with GIAZO in adults withulcerative colitis, 7% of male patients reported exacerbation of thesymptoms of ulcerative colitis. Symptoms include cramping, acuteabdominal pain and bloody diarrhea, sometimes fever, headache, and rash.Observe patients closely for worsening of these symptoms while ontreatment. If acute intolerance syndrome is suspected, promptlydiscontinue treatment with GIAZO.

Renal impairment, including minimal change nephropathy, acute andchronic interstitial nephritis, and, rarely, renal failure, has beenreported in patients given products that release mesalamine in thegastrointestinal tract. It is recommended that patients have anevaluation of renal function prior to initiation of GIAZO therapy andperiodically while on therapy. Exercise caution when using GIAZO inpatients with known renal dysfunction or a history of renal disease.

There have been reports of hepatic failure in patients with pre-existingliver disease who have been administered mesalamine. Because balsalazideis converted to mesalamine, caution should be exercised whenadministering GIAZO to patients with liver disease.

Patients with pyloric stenosis may have prolonged gastric retention ofGIAZO tablets, which may delay delivery of GIAZO to the colon.

Because clinical studies are conducted under widely varying conditions,adverse reaction rates observed in the clinical studies of a drug cannotbe directly compared to rates in the clinical studies of another drugand may not reflect the rates observed in practice.

In an in vitro study using human liver microsomes, balsalazide and itsmetabolites [5-aminosalicylic acid (5-ASA), N-acetyl-5-aminosalyicylicacid (N-Ac-5-ASA), 4-aminobenzoyl-β-alanine (4-ABA), andN-acetyl-4-aminobenzoyl-β-alanine (N-Ac-4-ABA)] were not shown toinhibit the major CYP enzymes evaluated (CYP1A2, CYP2C9, CYP2C19,CYP2D6, and CYP3A4/5). Therefore, balsalazide and its metabolites arenot expected to inhibit the metabolism of other drugs that aresubstrates of CYP1A2, CYP2C9, CYP2C19, CYP2D6, or CYP3A4/5.

Pregnancy Category B. Reproduction studies were performed in rats andrabbits at oral doses up to 2 g/kg/day, 2.5 and 4.9 times therecommended human dose based on body surface area for the rat andrabbit, respectively, and revealed no evidence of impaired fertility orharm to the fetus due to balsalazide disodium. There are, however, noadequate and well-controlled studies in pregnant women. Because animalreproduction studies are not always predictive of human response, thisdrug should be used during pregnancy only if clearly needed.

Mesalamine is known to cross the placental barrier.

It is not known whether balsalazide disodium or its metabolites areexcreted in human milk. Because many drugs are excreted in human milk,caution should be exercised when GIAZO is administered to a nursingwoman.

This invention is further illustrated by the following examples whichshould not be construed as limiting. The contents of all references,patents and published patent applications cited throughout thisapplication are hereby incorporated by reference.

EXAMPLES Example 1 Clinical Studies

The data described below reflect exposure of GIAZO in 565 ulcerativecolitis patients with mildly to moderately active disease. GIAZO wasevaluated in one placebo-controlled study (168 treated with GIAZO), oneactive-controlled study (210 treated with GIAZO); a subset of thesepatients also participated in an uncontrolled, open-label, extensionstudy (additional 187 treated with GIAZO). The population studied had amean age of 43.1 (range: 18-80) years; approximately 94% of patientswere <65 years old, 49% were male, and 84% were white.

Adverse Reactions/Contraindications

In the placebo-controlled study, a greater proportion of patientsexperienced an adverse reaction in the placebo group (68%) compared withthe GIAZO group (55%). The most common adverse reactions with GIAZO inmale patients were headache, nasopharyngitis, anemia, diarrhea, fatigue,pharyngolaryngeal pain, and urinary tract infection. A lower proportionof GIAZO (10%) patients discontinued treatment due to an adversereaction compared to the placebo group (13%). The majority of adversereactions were mild to moderate in severity. The percentage of patientswho experienced a serious adverse reaction was greater in the placebogroup (5.1%) than the GIAZO group (2.4%). The most common seriousadverse reactions were gastrointestinal disorders, which were mainlyassociated with symptoms of ulcerative colitis.

Adverse reactions occurring in at least 2% of male patients in theplacebo-controlled study are listed in Table 1.

TABLE 1 Adverse Reactions Experienced by at Least 2% of GIAZO - TreatedMale Patients and at a Rate Greater than Placebo in a Placebo-ControlledPhase 3 Study GIAZO 6.6 g/day PLACEBO Adverse Reaction N = 82 N = 37Anemia 3.7% 0% Diarrhea 3.7% 0% Pharyngolaryngeal Pain 3.7% 0% UrinaryTract Infection 3.7% 0% Arthralgia 2.4% 0% Insomnia 2.4% 0% Pain 2.4% 0%

Data collected from all three studies (placebo-controlled,active-controlled, and open-label) showed that female patients reportedadverse reactions more frequently than did male patients (76% and 66%,respectively).

The following adverse reactions, presented by body system, were reportedinfrequently (less than 1%) by GIAZO-treated ulcerative colitis patientsin controlled studies.

Cardiovascular and Vascular: increased blood pressure, increased heartrate

Dermatological: erythema nodosum, rash

Gastrointestinal Disorders: abdominal pain, constipation, defecationurgency, diarrhea, dry mouth, hard feces, flatulence, gastroesophagealreflux disease, vomiting

Hepatobiliary Disorders: increased aspartate aminotransferase

Infections and Infestations: gastroenteritis, upper respiratoryinfection

Musculoskeletal and Connective Tissue Disorders: arthralgia, back pain,myalgia

Nervous System Disorders: dizziness, lethargy

Respiratory, Thoracic and Mediastinal Disorders: dyspnea

General Disorders and Administrative Site Disorders: face edema,fatigue, malaise, pain, pyrexia, swelling

Because these reactions are reported voluntarily from a population ofunknown size, it is not always possible to reliably estimate theirfrequency or establish a causal relationship to drug exposure. Theseadverse reactions have been chosen for inclusion due to a combination ofseriousness, frequency of reporting, or potential causal connection tomesalamine.

The following adverse reactions have been identified during use ofbalsalazide-containing products in clinical practice:

Cardiovascular and Vascular: myocarditis, pericarditis, vasculitis

Dermatological: alopecia, pruritus

Gastrointestinal: pancreatitis

Respiratory: alveolitis, pleural effusion, pneumonia (with and withouteosinophilia)

Renal: interstitial nephritis, renal failure

The following additional adverse reactions have been identified duringpost-approval use in clinical practice of products which contain (or aremetabolized to) mesalamine:

Hepatobiliary Disorders: elevated liver enzymes (AST, ALT, GGT, LDH,alkaline phosphatase), elevated bilirubin, jaundice, cholestaticjaundice, cirrhosis, hepatocellular damage including liver necrosis andliver failure, Kawasaki-like syndrome including hepatic dysfunction.Some of these cases were fatal.

Absorption

After single-dose administration of 3.3 g GIAZO in 18 healthy subjects,the median time of peak plasma concentration (T_(max)) was 0.5 hr forbalsalazide, while the median T_(max) was 12 hr for both 5-ASA andN-Ac-5-ASA (Table 2). Pharmacokinetic parameters exhibited highvariability, with % CV ranging from 31% to 67% for AUC and from 27% to68% for C_(max).

After repeated doses of 3.3 g GIAZO tablets every 12 hours, steady-statewas achieved after about 3 days for balsalazide and all metabolites. TheAUC and C_(max) were the highest for N-Ac-5-ASA, followed by 5-ASA andbalsalazide. There was minimal accumulation of balsalazide, as suggestedby a 1.2-fold increase in AUC. On the other hand, a larger increase inthe systemic exposure to metabolites was observed at steady-state. Theaccumulation ratios based on AUC for the metabolites were 6.1 for 5-ASA,3.6 for N-Ac-5-ASA, 4.8 for 4-ABA, and 3.6 for N-Ac-4-ABA.

TABLE 2 Pharmacokinetic Parameters for Balsalazide and Metabolites(5-ASA and N-Ac-5-ASA) Following Single- and Repeated-Doses (Q12) of 3.3g Balsalazide Disodium as GIAZO (N = 18) Single Dose Repeated DoseParameter Mean SD Mean SD C_(max) (mcg/mL) Balsalazide 0.3 0.2 0.3 0.25-ASA 0.5 0.3 1.5 0.6 N-Ac-5-ASA 1.2 0.4 2.2 0.6 T_(max) ^(a) (hours)Balsalazide 0.5 (0.5-2)   0.5 (0.5-2)   5-ASA 12 (8-16) 12 (1.5-16)  N-Ac-5-ASA 12 (8-16) 10 (1-16) AUC_(tau) (mcg · h/mL) Balsalazide 1.30.7 1.6 0.9 5-ASA 2.2 1.6 13.4 6.3 N-Ac-5-ASA 5.9 2.9 21 6.4 AUC_(0-∞)(mcg · h/mL) Balsalazide 1.4 0.8 NA NA 5-ASA 8.5 3.9 NA NA N-Ac-5-ASA33.5 14.1 NA NA T_(1/2) ^(b) (hour) Balsalazide 1.9 0.7 8.4 12.4 5-ASA9.5^(b) 10.1 9.0 8.6 N-Ac-5-ASA 10.4^(b) 17.6 7.2 6.8 ^(a)Expressed asmedian and range. ^(b)N = 17.

Food Effect

After administration of single dose of 3.3 g (3×1.1 g tablets) of GIAZOwith a high-fat meal, the AUC of balsalazide was unaffected compared tofasted administration, but the presence of food reduced both peakconcentrations and AUC of the metabolites 5-ASA and N-Ac-5-ASA. A highfat meal increased the median T_(max) for balsalazide from 0.5 to 2hours; for 5-ASA from 12 to 24 hours; and for N-Ac-5-ASA from 12 to 24hours. Under fed conditions, the mean C_(max) was reduced by 44% forbalsalazide, 65% for 5-ASA, and 48% for N-Ac-5-ASA. No significantchanges were observed for AUC_(0-∞) for balsalazide; however, AUC_(0-∞)was reduced for 5-ASA by 46% and for N-Ac-5-ASA by 17%.

The binding of balsalazide to human plasma proteins was ≧99%; 5-ASA andN-Ac-5-ASA were 43% and 78% bound, respectively, to plasma proteins.

Following oral administration, balsalazide is cleaved by bacterialazoreduction to release equimolar quantities of 5-ASA, the activemoiety, and 4-ABA, a carrier moiety. Mesalamine (5-ASA) and 4-ABA arefurther acetylated to N-Ac-5-ASA and N-Ac-4-ABA, respectively in theintestinal mucosa and liver. The terminal half-life was 1.9 h forbalsalazide, 9.5 h for 5-ASA, and 10.5 h for N-Ac-5-ASA.

At steady-state following administration of repeated doses of 3.3 gGIAZO every 12 hours in healthy volunteers, the combined % of doseexcreted in urine for balsalazide and its metabolites over 12 hours was23%. The mean % of dose excreted in urine over 12 hours was 0.16% forbalsalazide, 4.6% for 5-ASA, 15.6% for N-Ac-5-ASA, 0.40% for 4-ABA, and1.8% for N-Ac-4-ABA.

Example 2 Carcinogenicity Studies

In a 24-month rat (Sprague Dawley) carcinogenicity study, oral (dietary)balsalazide disodium at doses up to 2 g/kg/day was not tumorigenic. Fora 50 kg person of average height this dose represents 2.5 times therecommended human dose on a body surface area basis. Balsalazidedisodium was not genotoxic in the following in vitro or in vivo tests:Ames test, human lymphocyte chromosomal aberration test, and mouselymphoma cell (L5178Y/TK+/−) forward mutation test, or mousemicronucleus test. However, it was genotoxic in the in vitro Chinesehamster lung cell (CH V79/HGPRT) forward mutation test.

The compound 4-aminobenzoyl-γ-alanine, a metabolite of balsalazidedisodium, was not genotoxic in the Ames test and the mouse lymphoma cell(L5178Y/TK+/−) forward mutation test but was positive in the humanlymphocyte chromosomal aberration test.N-acetyl-4-aminobenzoyl-γ-alanine, a conjugated metabolite ofbalsalazide disodium, was not genotoxic in Ames test, the mouse lymphomacell (L5178Y/TK+/−) forward mutation test, or the human lymphocytechromosomal aberration test. Balsalazide disodium at oral doses up to 2g/kg/day, 2.5 times the recommended human dose based on body surfacearea, was found to have no effect on fertility and reproductiveperformance in rats.

Example 3 Placebo-Controlled Study

A double-blind, placebo-controlled, multi-center study was conducted in250 adult patients with mildly to moderately active ulcerative colitis.The study population was primarily white (84%), had a mean age of 44years (7% age 65 years or older), and 49% were men. Disease activity wasassessed using a modified Mayo Disease Activity Index¹ (MMDAI), whichwas a sum of four subscores (bowel frequency, rectal bleeding,endoscopic appearance, and physician's global assessment), each rangingfrom 0 to 3, with higher scores indicating worse disease. The medianbaseline MMDAI score was 8. Patients were randomized 2:1 to receive 8weeks of treatment with either GIAZO 3.3 g twice daily or placebo.

The primary efficacy endpoint was to compare the proportion of patientsthat achieved clinical improvement and improvement in the rectalbleeding subscale of the MMDAI at the end of 8 weeks of treatment forGIAZO vs. placebo. Clinical Improvement was defined as having both a ≧3point improvement from baseline in the MMDAI score and a ≧1 pointimprovement from baseline in the rectal bleeding subscore. Two keysecondary efficacy endpoints compared the proportion of patients withClinical Remission and Mucosal Healing at the end of 8 weeks oftreatment for GIAZO vs. placebo. Clinical Remission was defined as ascore of 0 for rectal bleeding and a combined score of ≦2 for bowelfrequency and physician's assessment using the MMDAI subscale; theendoscopic sub-score was not considered in this definition. MucosalHealing was defined as an endoscopy/sigmoidoscopy score of 0 or 1, wherea score of 1 could include signs of erythema or decreased vascularpattern; by definition, the presence of friability indicated a score of2 or 3.

After 8 weeks of treatment, the proportion of patients showing ClinicalImprovement was greater for the GIAZO-treated group compared to theplacebo group (Table 3).

TABLE 3 Proportion of Patients with Clinical Improvement* at Week 8 forthe Total Population and by Gender Subgroups GIAZO Placebo p-value TotalPopulation 55% 40% 0.0237 Males 57% 20% Females 54% 58% *ClinicalImprovement: ≧3 improvement in MMDAI score and ≧1 point improvement inrectal bleeding.

These differences were statistically significant in the overallpopulation; however, these effects were entirely driven by the resultsin the male subpopulation. With adjustment for multiplicity,statistically significant differences were also seen in the malepatients for Clinical Remission (35% with GIAZO vs. 13% for placebo) andfor Mucosal Healing (52% with GIAZO vs. 20% for placebo). Effectivenessof GIAZO was not demonstrated in the female subpopulation in theclinical trial.

CONCLUSIONS

Instruct patients not to take GIAZO if they have a hypersensitivity tosalicylates (e.g., aspirin).

Instruct patients to take GIAZO with food.

Instruct patients to contact their health care provider if theyexperience a worsening of their ulcerative colitis symptoms, because itcould be due to a reaction to GIAZO.

Instruct patients to make sure they let their health care provider know:

if they have or are later diagnosed with renal dysfunction. Damage tothe kidney has been observed in some people given medications similar toGIAZO.

if they have or are later diagnosed with liver disease. Worsening liverdisease has been observed in some people given medications similar toGIAZO.

if they have or are later diagnosed with pyloric stenosis, because GIAZOtablets may be slow to pass through their digestive tract.

INCORPORATION BY REFERENCE

The contents of all references, patents, pending patent applications andpublished patents, cited throughout this application are herebyexpressly incorporated by reference.

EQUIVALENTS

Those skilled in the art will recognize, or be able to ascertain usingno more than routine experimentation, many equivalents to the specificembodiments of the invention described herein. Such equivalents areintended to be encompassed by the following claims.

1. A method for treating a gastrointestinal disorder in a male subjectcomprising administering to the male subject in need of treatment atherapeutically effective amount of balsalazide with food.
 2. The methodclaim 1, wherein the therapeutically effective amount comprises about6.5 to about 6.8 g per day.
 3. The method claim 1, wherein thetherapeutically effective amount comprises about 6.6 g per day.
 4. Themethod claim 1, wherein the therapeutically effective amount comprisesabout 6.75 g per day.
 5. The method of claim 1, wherein thetherapeutically effective amount is a dosage regimen of three tablets ofthe formulation two times each day, wherein each tablet comprises about1100 mg of balsalazide.
 6. The method of claim 5, wherein thebalsalazide tablet is a film-coated tablet.
 7. The method of claim 1,wherein the therapeutically effective amount is a dosage regimen ofthree capsules of the formulation three times each day, wherein eachcapsule comprises about 750 mg of balsalazide.
 8. The method of claim 1,wherein the administration to the subject occurs between about 30minutes prior to about 1 hour after consuming food.
 9. The method ofclaim 1, wherein the gastrointestinal disorder comprises ulcerativecolitis.
 10. The method of claim 9, wherein the ulcerative colitis ismild to moderately active ulcerative colitis. 11-35. (canceled)
 36. Themethod of claim 1, wherein the administration of the therapeuticallyeffective amount of balsalazide decreases a MMDAI score by 3 or morepoints.
 37. The method of claim 36, wherein the administration of thetherapeutically effective amount of balsalazide decreases the rectalbleeding component of the MMDAI score by 1 or more points.
 38. Themethod of claim 9, wherein the ulcerative colitis is induced intoclinical remission.
 39. The method of claim 38, wherein the clinicalremission is defined by MMDAI component scores of zero for rectalbleeding and a combined score of 2 or less for bowel frequency andphysician's assessment.
 40. The method of claim 1, wherein theadministration of the therapeutically effective amount of balsalazideinduces mucosal healing in the male subject.
 41. The method of claim 40,wherein the mucosal healing is defined as an improvement inendoscopy/sigmoidoscopy score to 0 or
 1. 42. The method of claim 1,further comprising the step of informing the male subject that thebalsalazide is indicated for the treatment of mildly to moderatelyactive ulcerative colitis in a male patient 18 years of age or older.43. The method of claim 1, further comprising the step of informing themale subject that the usual dose of balsalazide for treating activeulcerative colitis in adult male patients is three tablets comprising1.1 grams per tablet taken twice per day for a total of 6.6 grams ofbalsalazide per day with food.
 44. The method of claim 1, wherein themale subject does not have a hypersensitivity to salicylates,balsalazide, or a balsalazide metabolite.
 45. The method of claim 1,further comprising informing the male subject the possibility of adversereaction that include anemia, diarrhea, pharnygolaryngeal pain, urinarytract infection, arthralgia, insomnia, and pain.